Event Notification Report for May 1, 2002
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
04/30/2002 - 05/01/2002
** EVENT NUMBERS **
38885 38886 38887 38888
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|Hospital |Event Number: 38885 |
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| REP ORG: VA MEDICAL CENTER |NOTIFICATION DATE: 04/30/2002|
|LICENSEE: VA MEDICAL CENTER |NOTIFICATION TIME: 15:35[EDT]|
| CITY: SAINT LOUIS REGION: 3 |EVENT DATE: 04/30/2002|
| COUNTY: STATE: MO |EVENT TIME: [CDT]|
|LICENSE#: 24-00144-5 AGREEMENT: N |LAST UPDATE DATE: 04/30/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |BRENT CLAYTON R3 |
| |ERIC LEEDS NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: LARRY CHANDLER | |
| HQ OPS OFFICER: RICH LAURA | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|BAB1 20.2201(a)(1)(i) LOST/STOLEN LNM>1000X | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| VA REPORTS LOST RADIOACTIVE MATERIAL LATER LOCATED IN A LANDFILL |
| |
| "1. Part 20.2201(a) [telephone report]: |
| |
| a. A telephone report was not made since the circumstances related to the |
| loss of licensed materials were identified to the licensee by the Nuclear |
| Regulatory Commission (NRC) and are not based on specific information |
| verified by the license or on official records. |
| |
| b. Neither the NRC nor the state regulatory agency (Illinois Department of |
| Nuclear Safety) with purview over the landfill has provided the licensee any |
| information other than telephone summaries and digital photographs. |
| |
| C. The estimate of the quantity of lost licensed materials was completed |
| post hoc and is not based on measurements performed by the licensee. |
| |
| d. The licensee became aware of loss of licensed materials on March 29, |
| 2002. |
| |
| 2. Part 20.2201(b)(i) [description of the licensed material involved, |
| including kind, quantity, and chemical and physical form]: |
| |
| a. The licensed material was I-131 as identified by spectral analysis at the |
| landfill by the state regulatory agency. Since the material could not be |
| recovered, the exact chemical form could not be determined. However, in |
| light of subsequent investigation, the form was probably inorganic NaI bound |
| to Sephadex beads. |
| |
| b. The gamma factor for I-131 is 2.2 R./hr per mCi @1cm. |
| |
| c. The state regulatory agency reported the following exposure rates |
| measured using a Bicron internal chamber meter. |
| |
| (1) 125 mR/hr @ contact |
| |
| (2) 50 mR/hr through side of truck |
| |
| (3) 0.65 mR/hr @ 1 meter |
| |
| d. The three different readings appear to be somewhat contradictory. |
| However, since the actual distance for the first two measurements is |
| uncertain and less error is likely in exposure rate measurements at a known |
| distance. the third measurement is considered the most accurate to use to |
| estimate activity. |
| |
| e. The waste materials from the laboratory were not specifically recovered |
| or identified. The following three possible basis were used to estimate |
| activity: the exposure rate measurements by the state regulatory agency, the |
| usual laboratory protocols, and recreation of exposure rate measurements in |
| a laboratory setting. |
| |
| (1) Using corrected distances for the exposure rate measurements and the |
| gamma factor for I-131, the measurement at one meter calculates to an |
| estimated activity of approximately 3 mCi. |
| |
| (2) The usual laboratory protocol is to use either 1 or 2 mCi I-131 run |
| through a column. The highest activity possible on the column is 1.9 mCi, |
| corresponding to a maximum doping of 2 mCi, with the poorest binding success |
| of 5%. |
| |
| (3) Laboratory measurements were taken using a 16 uCi I-131 capsule and a GM |
| detector calibrated to CS-137 and with a thick-walled tube. The exposure |
| rate measurement at contact with the thin plastic container with the capsule |
| nearest the probe was 45 mR/hr. This represents the closest likely proximity |
| implied by contact. Under this geometry, a reading of 125 mR/hr could be |
| produced by as little as 44 uCi I-131. However, the rate drops to less than |
| 0.05 mR/hr at 6 inches, due in part to the influence of the beta component. |
| This indicates an activity in the millicurie range was involved in the |
| incident, and the contact exposure rate measurement was likely not taken |
| at contact, but at about 8 cm. |
| |
| (4) The estimate for activity is approximately 2 mCi. |
| |
| 3. Part 20.2201(b)(ii) [a description of the circumstances under which the |
| loss or theft occurred]: |
| |
| a. The loss of licensed materials involved the Roxanna, Illinois, landfill. |
| The loss was identified by the landfill operator during routine radiation |
| monitoring for incoming waste shipments on March 28, 2002. The landfill |
| operator reported higher than expected radiation monitoring results and |
| notified the state regulatory agency. The state contacted the NRC. The NRC |
| contacted the VA National Health Physics Program who then contacted the |
| licensee. |
| |
| b. The loss involved I-131 contaminated glassware which was identified in a |
| truck hauling waste from the licensee to the landfill. The landfill is |
| approximately 20 miles from the licensee, John Cochran Division, in downtown |
| St. Louis: The waste was probably generated in a research laboratory in |
| Building 1 of the John Cochran Division. |
| |
| c. Workers assigned to the licensee Environmental Management Service (EMS) |
| collect waste at the end of each work day from research laboratories. The |
| waste is initially placed in carts and then relocated to a dumpster at the |
| loading dock. The contract waste carrier empties the waste collected in the |
| dumpster on a daily basis, normally at night. The waste is then transported |
| to a transfer station and consolidated with other waste. The consolidated |
| waste is relocated to the landfill using a semi-trailer. |
| |
| 4. Part 20.2201(b)(iii) [a statement of disposition. or probable |
| disposition, of the licensed material involved] |
| |
| a. Disposition of the radioactive materials was under the purview of the |
| state regulatory agency. |
| |
| b. The state regulatory agency directed the landfill operator to bury the |
| waste materials. |
| |
| 5. Part 20.2201(b)(iv) [exposures of individuals to radiation, circumstances |
| under which the exposures occurred, and the possible total effective dose |
| equivalent to persons in unrestricted areas]: |
| |
| a. The following individuals had the most potential for exposure |
| |
| (1) EMS (Environmental Management Service, i.e. Housekeeper) personnel |
| picking up waste and transporting it to dumpster |
| |
| (2) Driver of truck hauling waste from VA to transfer point ( first truck ) |
| |
| (3) Driver of truck hauling consolidated waste from transfer point to |
| landfill ( 2nd truck ) |
| |
| (4) State of Illinois (IDNS) responding personnel |
| |
| (5) Landfill personnel were not involved in the effort to recover the |
| contaminated object. The potential exposure of personnel other than the |
| above must be considered small in comparison. |
| |
| b. Estimated exposure |
| |
| (1) EMS workers |
| |
| Estimated duration of exposure = 10 min (0.16 hr) |
| Average proximity 3 feet (bag of waste is carried in large cart with other |
| bags) |
| Inverse-square correction, using 0.65 mR/hr at 1.13 meters 0.83 mR/hr |
| Add 20% for lack of shielding by dump truck =1.0 mR/hr |
| Estimated exposure 1.0 mR/hr x 0.16 hr = 0.16 mR |
| |
| (2) Driver of first truck |
| |
| Estimated duration of exposure 1 hr |
| Average proximity = 10 feet (3 m) |
| Inverse square correction, using at 0.65 mR/hr @ 1.13 m. through truck bed |
| |
| 0.65 mR/hr x (1.13/3)squared = 0.09 mR/hr |
| |
| Total estimated exposure: 1 hr x 0.09 mR/hr = 0.09 mR |
| |
| (3) Driver of 2nd truck (semi-trailer) . |
| |
| Estimated duration of exposure = 1 hr |
| Average proximity 17 feet (5 m) |
| Inverse square calculation, staring at 0.65 mr/hr @ 1.13 m, through truck |
| bed |
| |
| 0.65 mR./hr x (1.13/5) squared = 0.03 mR/hr |
| |
| Total estimated exposure: 1 hr x 0.03 mR/hr =0.03 mR |
| |
| (4) IDNS responding personnel = N/A; occupationally exposed and monitored |
| |
| 6. Part 20.2201(b)(v) [actions that have been taken, or will be taken, to |
| recover the material]: |
| |
| a. Disposition of the radioactive materials was under the purview of the |
| state regulatory agency. |
| |
| b. The state regulatory agency directed the landfill operator to bury the |
| waste materials. |
| |
| c. The licensee attempted to recover the material by driving to the |
| landfill, prior to being informed that the material had been buried. The |
| licensee does not have any authority to take further actions to recover the |
| material nor is recovery currently possible. |
| |
| 7. Part 20.2201(b)(vi) [procedures or measures that have been, or will be, |
| adopted to ensure against a recurrence of the loss or theft of licensed |
| material]: |
| |
| a. Investigation by the licensee verified that current policies and |
| procedures regarding waste control are adequate and should have prevented |
| such an incident. At some point, therefore, procedures were apparently not |
| followed. Lab workers can not recall any breach of procedures. Similar waste |
| has been produced many times in the past without incident, and the |
| ergonomics of the laboratory do not point to any probable mis-step. |
| Therefore, remediation efforts will be broader than a focus on handling of |
| the specific type of waste in question. |
| |
| b. The corrective actions will involve screening of all waste generated from |
| areas where external radiation detectable by NaI instruments is produced. |
| All laboratories possessing photon-producing isotopes of energies greater |
| than approximately 20 KeV, in quantity greater than 1 micro-curie, will be |
| required to screen all sanitary and DIS waste with a NaI detector prior to |
| release into the environment. The new standards will require that equipment, |
| procedures, and competency of screeners be reviewed and approved by the RSO |
| for each area. The level of detail in the existing procedure for screening |
| of DIS waste has been increased to include removing interposed shielding, |
| measuring each container at multiple positions, using the most sensitive |
| scale, and a standard for the background reading. This more detailed |
| procedure will be applied to all labs utilizing DIS, and will also be |
| applied to screening of sanitary waste by those labs required to do so. The |
| procedure will be reviewed by the Radiation Safety Committee on May 2, 2002. |
| Users will be required to implement the new procedure by June 1, but will |
| probably do so earlier. NaI detectors have been ordered; first deliveries |
| are expected by the May 1. Until the equipment arrives and the program is |
| fully implemented, routine trash pickups of affected areas has been halted. |
| All waste is screened by the RSO, using the limited NaI technology currently |
| available, before release. |
| |
| c. The requirement for sanitary waste screening will become a condition |
| during both permit approval and renewal, and whenever an affected isotope is |
| added to the authorization. This condition will apply equally in Nuclear |
| Medicine and Research laboratories at the St. Louis site of use. RSO review |
| of equipment specifications and operator competency will be included in the |
| approval process. This program has already been implemented. |
| |
| d. Certain logistics of the waste-handling process, such as: how long waste |
| is accumulated before screening, whether waste storage is centralized, arid |
| how unscreened waste is stored, etc., can only be developed through |
| practice. However, once best practices are developed, affected labs will |
| be required to adopt diem, and will not be allowed to change them without |
| review and approval of the RSO. Logistics will be under review through May, |
| 2002; final practices will be in place by June 1, 2002. |
| |
| e. DIS procedures and compliance will continue to be monitored during |
| routine inspections and the results reported to the Radiation Safety |
| Committee. |
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|Other Nuclear Material |Event Number: 38886 |
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| REP ORG: FMC IDAHO LLC |NOTIFICATION DATE: 04/30/2002|
|LICENSEE: FMC IDAHO LLC |NOTIFICATION TIME: 15:37[EDT]|
| CITY: POCATELLO REGION: 4 |EVENT DATE: 04/29/2002|
| COUNTY: POWER STATE: ID |EVENT TIME: 15:30[MDT]|
|LICENSE#: 11-27071-01 AGREEMENT: N |LAST UPDATE DATE: 04/30/2002|
| DOCKET: 03032191 |+----------------------------+
| |PERSON ORGANIZATION |
| |BLAIR SPITZBERG R4 |
| |JOHN HICKEY NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: JAMES RICE | |
| HQ OPS OFFICER: LEIGH TROCINE | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|IBBE 30.50(b)(2) SAFETY EQUIPMENT FAILUR| |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| MALFUNCTIONING (RUPTURED), CESIUM-137, INSERTION SOURCE ON A BERTHOLD
|
| DENSITY DEVICE AT FMC IDAHO LLC IN POCATELLO, IDAHO |
| |
| Prior to the event, a representative from FMC Idaho LLC (an elemental |
| phosphorous plant which has been shutdown) contacted Thermo Measure Tech |
| (used to be TN) to remove several density devices at the plant. The plan |
| was to have several devices removed, packed up, and shipped back to Thermo |
| Measure Tech. |
| |
| During the process of removing a Berthold (model number LB300, serial number |
| 2576-10-94) device with a 15-millicurie, cesium-137, insertion source (used |
| to monitor tank levels), the cable which lowers the source pellet into the |
| tube parted. Workers improvised, got a hold of the wire, and pulled it back |
| up. When the source came out of the top, it became obvious that it had |
| ruptured. All of the contaminated items (the source, a rag, a pair of |
| gloves) were then put back into the tube, and the top was placed back on. |
| The area was surveyed, and there was no contamination outside of the tube. |
| Everything was locked up, and the area was marked off. |
| |
| The licensee contacted Berthold USA. Because the device was manufactured in |
| Germany, Berthold USA notified Berthold in Germany. The licensee |
| anticipates that Berthold will arrange to take possession of the device. A |
| manufacturer representative told the licensee that they had never had one of |
| these devices rupture in this fashion before. |
| |
| The licensee notified the NRC Region 4 office (Christine Maier and Mark |
| Shaffer). |
| |
| (Call the NRC operations center for a licensee contact telephone number.) |
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|Power Reactor |Event Number: 38887 |
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| FACILITY: POINT BEACH REGION: 3 |NOTIFICATION DATE: 04/30/2002|
| UNIT: [] [2] [] STATE: WI |NOTIFICATION TIME: 17:26[EDT]|
| RXTYPE: [1] W-2-LP,[2] W-2-LP |EVENT DATE: 04/30/2002|
+------------------------------------------------+EVENT TIME: [CDT]|
| NRC NOTIFIED BY: RICK ROBBINS |LAST UPDATE DATE: 04/30/2002|
| HQ OPS OFFICER: RICH LAURA +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |BRENT CLAYTON R3 |
|10 CFR SECTION: | |
|AUNA 50.72(b)(3)(ii)(B) UNANALYZED CONDITION | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|2 N N 0 Refueling |0 Refueling |
| | |
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EVENT TEXT
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| PRESSURIZER SAFETY VALVE SETPOINT DRIFT AT POINT BEACH UNIT 2 |
| |
| "On April 24, 2001, a vendor conducting offsite testing of the Point Beach |
| Nuclear Plant (PBNP) Unit 2 RCS pressurizer safely valves' reported that |
| safety valve 2RC-435 failed to lift at a test pressure of 2660 psig. The |
| lift pressure specification for this valve is from 2440 to 2551 psig. In |
| accordance with code requirement, the second in-service Unit 2 pressurizer |
| safety valve was sent to the vendor for set point testing. The vendor also |
| initiated an investigation to determine why the first valve failed to lift. |
| |
| "On April 29, 2002, our engineering department received a telecopy report of |
| that investigation. After evaluation, we determined this event to be |
| reportable at 1129, 4-30-02. The valve at position 2RC-435 was last tested |
| in November 2000 by the same vendor. At that time the valve set point was |
| determined to be within specification. In accordance with the vendor's |
| normal practice, a jack and lap procedure was done following the set point |
| test to lap the valve disc and nozzle to insure that the valve is leaktight |
| with undamaged seats. It was during this process that the valve became |
| incapable of lifting at the specified pressure. The valve assembly was |
| corrected and the set point retested with satisfactory results. The second |
| safety valve that was shipped for testing subsequent to the failure of the |
| first valve has also been tested and was found to lift within the specified |
| range. Our investigation of the circumstances of the event is continuing. |
| |
| "The required design capacity for the RCS pressurizer safety valves assumes |
| the use of 2 valves based on RCS pressure not exceeding the maximum code |
| allowable 110% of design pressure for the maximum calculated in surge of |
| reactor coolant into the pressurizer. We have concluded that we operated |
| PBNP Unit 2 with one inoperable pressurizer safety valve for the past cycle. |
| The second Unit 2 safety valve has been tested and proven to be operable. |
| This event is reportable both as a condition prohibited by the Technical |
| Specification (LCO 3.4.10) and as an event or condition that resulted in an |
| unanalyzed condition that had the potential to significantly degrade plant |
| safety. An evaluation of the significance of this condition will be |
| performed." |
| |
| The NRC Resident Inspector has been notified. |
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|Power Reactor |Event Number: 38888 |
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| FACILITY: ARKANSAS NUCLEAR REGION: 4 |NOTIFICATION DATE: 04/30/2002|
| UNIT: [] [2] [] STATE: AR |NOTIFICATION TIME: 19:13[EDT]|
| RXTYPE: [1] B&W-L-LP,[2] CE |EVENT DATE: 04/30/2002|
+------------------------------------------------+EVENT TIME: 18:01[CDT]|
| NRC NOTIFIED BY: JAMES PORTER |LAST UPDATE DATE: 05/01/2002|
| HQ OPS OFFICER: RICH LAURA +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: UNUSUAL EVENT |BLAIR SPITZBERG R4 |
|10 CFR SECTION: |SUSIE BLACK NRR |
|AAEC 50.72(a) (1) (i) EMERGENCY DECLARED |TIM MCGINTY IRO |
| |RENE ZAPATA FEMA |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|2 N N 0 Hot Standby |0 Hot Standby |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
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| UNUSUAL EVENT AT ANO2 DUE TO BORON RESIDUE AT PRESSURIZER HEATER
SLEEVE N-2 |
| |
| "On 4/30/02, while performing a planned Reactor Coolant System Integrity |
| Inspection following the 2R15 refueling outage, with the Reactor Coolant |
| System at normal operating temperature and pressure (Mode 3), an inspector |
| discovered small traces of boric acid on pressurizer heater sleeve N-2. |
| Based on the subsequent evaluation, pressurizer heater sleeve N-2 has been |
| determined to have had pressure boundary leakage. No current leakage is |
| detectable. The Unit 2 Tech Spec 3.4.6.2 does not allow operation in Modes |
| 1-4 with any pressure boundary leakage. Therefore a plant cooldown is being |
| initiated to place Unit 2 in Mode 5. Based on this criteria, the condition |
| is reportable upon declaring a Notification of Unusual Event (EAL 2.1) and |
| Degraded Condition which is reportable per 1OCFR50.72(b)(3)(ii)(A)". |
| |
| The NRC Resident Inspector was notified. |
| |
| |
| * * * UPDATE ON 5/1/02 @ 0331 BY AHO TO GOULD * * * |
| |
| NOUE terminated at 0221CDT. Plant in mode 5 (cold shutdown) |
| |
| The NRC Resident Inspector will be notified. |
| |
| Notified FEMA(Zapata), REG 1 RDO(Spitzberg), EO(Black) and IRO(McGinty) |
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